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November 13th, 2015:

E-cigarettes and children: advocates walking on both sides of the street?

http://blogs.bmj.com/tc/2015/11/13/e-cigarettes-and-children-advocates-walking-on-both-sides-of-the-street/

In a 2014 open letter to the WHO’s director general Margaret Chan signed by 53 researchers, it was argued “Controls on [ecigarette] advertising to nonsmokers, and particularly to young people are certainly justified, but a total ban would have many negative effects, including protection of the cigarette market and implicit support for tobacco companies. It is possible to target advertising at existing smokers where the benefits are potentially huge and the risks minimal.”

Clive Bates who “had a hand” in organising the letter but curiously did not sign it, is a former director of England’s Action on Smoking and Health. In that role, Bates directed and wrote one of the most excoriating critiques ever published of the tobacco industry’s long standing (and still running) denials of its designs on children.

In the October 2000 Danger in the Playground, Bates documented many of the most telling examples of candid industry talk about the vital role of children to the future of tobacco industry profitability. This accompanying powerpoint presentation (also authored by Bates) rubs it in even harder. These revelations were all made in internal tobacco industry documents released through the US Master Settlement Agreement between US state governments the tobacco industry, millions of which are now freely available here.

The tobacco industry’s business model about the importance of youth smoking was never put more succinctly than in this 1984 document from an RJ Reynolds tobacco official: “If younger adults turn away from smoking, the industry will decline, just as a population which does not give birth will eventually dwindle.” (“younger adults” was industry code from the mid 1970s for children and young adults, to be used in all written communications)

In a 2000 press statement at the time of the launch of the publication, Bates said “When you look at what they say privately, and compare it to their public posturing, the whole idea that tobacco companies might be working against teenage smoking is revealed as sinister self-serving public relations. The more they try to define smoking as only for adults, the more they are saying ‘hey kids, smoking’s for grown-ups’ with a sly nod and a cynical wink.”

Today, Bates runs his own consultancy business and is a leading advocate of ecigarettes. Of 220 tweets he posted between Oct 1 and Nov 1, 80% were about ecigarettes. On a recent blog he wrote that when it comes to ecigarettes “There is little evidence of marketing to children, only assertions that certain ads or brands are designed to appeal to children but with no empirical evidence, and apparently minimal understanding of modern advertising.”

On reading this, I was struck by how far Bates appears to have moved in the 15 years since he wrote Danger in the Playground and so tweeted a juxtaposition of the two quotes above, asking “which Clive Bates to believe?”

Bates replied challenging this apparent inconsistency, arguing that his 2000 statement referred to tobacco companies while his 2015 statement referred to ecigarette companies. He argued that currently, the vaping market is worth 100 times less than the cigarette market and that “nearly all vape customers come from the ranks of existing smokers”, which he said explains why adult smokers are the target market for ecigs.

The same analysis can of course be applied to the current contribution of young smokers to the total cigarette market. For example, an early Australian analysis showed that while in one year the value of the underage market to manufacturers was $AUD18.7million, if 50% of young smokers continued to smoke, they would contribute $AUD112 billion at current prices to the industry across their lifetime.

Bates knows perfectly that tobacco companies understand the importance of smoking uptake by children to their future, but seems to believe that such a thought has never crossed the minds of ecig manufacturers.

In an extraordinary statement, he wrote that “there are good reasons why the e-cigarette companies, even tobacco owned ones, would not target adolescents … demand, reputational, legal and regulatory risk etc … it would be bad business.”

In a 2014 open letter to the WHO’s director general Margaret Chan signed by 53 researchers, it was argued “Controls on [ecigarette] advertising to nonsmokers, and particularly to young people are certainly justified, but a total ban would have many negative effects, including protection of the cigarette market and implicit support for tobacco companies. It is possible to target advertising at existing smokers where the benefits are potentially huge and the risks minimal.”

Clive Bates who “had a hand” in organising the letter but curiously did not sign it, is a former director of England’s Action on Smoking and Health. In that role, Bates directed and wrote one of the most excoriating critiques ever published of the tobacco industry’s long standing (and still running) denials of its designs on children.

In the October 2000 Danger in the Playground, Bates documented many of the most telling examples of candid industry talk about the vital role of children to the future of tobacco industry profitability. This accompanying powerpoint presentation (also authored by Bates) rubs it in even harder. These revelations were all made in internal tobacco industry documents released through the US Master Settlement Agreement between US state governments the tobacco industry, millions of which are now freely available here.

The tobacco industry’s business model about the importance of youth smoking was never put more succinctly than in this 1984 document from an RJ Reynolds tobacco official: “If younger adults turn away from smoking, the industry will decline, just as a population which does not give birth will eventually dwindle.” (“younger adults” was industry code from the mid 1970s for children and young adults, to be used in all written communications)
In a 2000 press statement at the time of the launch of the publication, Bates said “When you look at what they say privately, and compare it to their public posturing, the whole idea that tobacco companies might be working against teenage smoking is revealed as sinister self-serving public relations. The more they try to define smoking as only for adults, the more they are saying ‘hey kids, smoking’s for grown-ups’ with a sly nod and a cynical wink.”

Today, Bates runs his own consultancy business and is a leading advocate of ecigarettes. Of 220 tweets he posted between Oct 1 and Nov 1, 80% were about ecigarettes. On a recent blog he wrote that when it comes to ecigarettes

“There is little evidence of marketing to children, only assertions that certain ads or brands are designed to appeal to children but with no empirical evidence, and apparently minimal understanding of modern advertising.”

On reading this, I was struck by how far Bates appears to have moved in the 15 years since he wrote Danger in the Playground and so tweeted a juxtaposition of the two quotes above, asking “which Clive Bates to believe?”

Bates replied challenging this apparent inconsistency, arguing that his 2000 statement referred to tobacco companies while his 2015 statement referred to ecigarette companies. He argued that currently, the vaping market is worth 100 times less than the cigarette market and that “nearly all vape customers come from the ranks of existing smokers”, which he said explains why adult smokers are the target market for ecigs.

The same analysis can of course be applied to the current contribution of young smokers to the total cigarette market. For example, an early Australian analysis showed that while in one year the value of the underage market to manufacturers was $AUD18.7million, if 50% of young smokers continued to smoke, they would contribute $AUD112 billion at current prices to the industry across their lifetime.

Bates knows perfectly that tobacco companies understand the importance of smoking uptake by children to their future, but seems to believe that such a thought has never crossed the minds of ecig manufacturers.

In an extraordinary statement, he wrote that “there are good reasons why the e-cigarette companies, even tobacco owned ones, would not target adolescents … demand, reputational, legal and regulatory risk etc … it would be bad business.”

We recommend

The marketing of e-cigarettes: a UK snapshot mhefler, TC News, 2013 –  http://blogs.bmj.com/tc/2013/04/06/the-marketing-of-e-cigarettes-a-uk-snapshot/

Eat, Drink, Smoke, Vape, Run. tomfardon, Thorax blog, 2014 – http://blogs.bmj.com/thorax/2014/01/11/eating-drink-smoke-vape-run/

WHO report on regulation of e-cigarettes and similar products, bfreeman, TC News, 2014 – http://blogs.bmj.com/tc/2014/08/27/who-report-on-regulation-of-e-cigarettes-and-similar-products/

How to dramatically reduce smoking without banning tobacco sales, bfreeman, TC News, 2015 – http://blogs.bmj.com/tc/2015/09/21/how-to-dramatically-reduce-smoking-without-banning-tobacco-sales/

Tasmania: Legislation drafted to implement a Tobacco Free Generation, mhefler, TC News, 2014 – http://blogs.bmj.com/tc/2014/11/04/tasmania-legislation-drafted-to-implement-a-tobacco-free-generation/

Exposing Mr Butts’ tricks of the trade. Introduction. K M Cummings et al., Tob Control, 2002 – http://tobaccocontrol.bmj.com/cgi/pmidlookup?view=long&pmid=11893809

The retail environment for tobacco: a barometer of progress towards the endgame. Lisa Henriksen, Tob Control, 2015 – http://tobaccocontrol.bmj.com/content/24/e1/e1.extract

Tobacco harm reduction and e-cigarettes: setting a unified research agenda, mhefler, TC News, 2013 – http://blogs.bmj.com/tc/2013/05/29/tobacco-harm-reduction-and-e-cigarettes-setting-a-unified-research-agenda/

Taking aim at the bull’s-eye: the nicotine in tobacco products. C E Douglas, Tob Control, 1998 – http://tobaccocontrol.bmj.com/cgi/pmidlookup?view=long&pmid=9825406

Point of Sale Display: A Call to Action on Prohibition of Tobacco Products in Nepal, bfreeman, TC News, 2015 – http://blogs.bmj.com/tc/2015/08/05/point-of-sale-display-a-call-to-action-on-prohibition-of-tobacco-products-in-nepal/

http://www.clivebates.com Clive Bates

Professor Chapman’s blog is largely based on comparing what I said in a report for Action on Smoking and Health (ASH) in 2000 about the conduct of tobacco companies with what I and many others are saying now about e-cigarette advertising. The key weakness in Professor Chapman’s argument is that the statements he compares were about two different things in a completely changed context.

My 2000 ASH report “PR in the Playground” was not just about tobacco companies: it was about about the useless and cynical youth anti-smoking initiatives run by tobacco companies. Tobacco companies running campaigns to persuade young people not to smoke were never going to be convincing or effective and that report shows why. They were mainly about protecting the reputation of tobacco companies – hence the ‘PR’ in the title. I haven’t changed my views about those programmes one bit, though I don’t know if they still exist.

But e-cigarette companies do not have programmes like this to my knowledge and Professor Chapman doesn’t suggest they do. My recent statements were about e-cigarettes, not cigarettes – another important difference. So he is comparing statements I made 15 years ago with statements made recently about something completely different in a radically changed landscape: there were no e-cigarettes in 2000. It’s not that surprising the statements look different.

I hope that Professor Chapman is fully aware of the potential dangers built into the positions he holds. It would be a major public health error to treat cigarettes and e-cigarettes the same way, given the very significant differences in risk – e-cigarettes are likely to be at least 95% lower risk than smoking, based on what we know of the toxic constituents of vapour. For example, an important effect of banning e-cigarette advertising could be to protect the incumbent cigarette trade from competition from a disruptive low-risk technology that helps people to quit smoking – thus increasing harm. In the UK, we have evolved a quite pragmatic approach to controls on e-cigarette advertising, which is similar to that used to control alcohol advertising. You don’t need a total ban to deal with the odd rogue advertisement (and it will always be possible to find these in any sector). The UK Committee on Advertising Practice reports that the e-cigarette code is working well and shaping the behaviour of advertisers in the way intended.

We rightly ban tobacco advertising in the EU because smoking kills 700,000 EU citizens per year. But no such justification exists for banning e-cigarette advertising. The most likely effect of e-cigarettes is to reduce the smoking related death toll in future – a negative death toll – assuming they are allowed to compete.

The problem of unintended consequences goes beyond banning e-cigarette advertising. Much of the hostility towards e-cigarettes in the field of tobacco control, if translated into policies, misinformation or taxes, could have the effect of protecting cigarette sales and supporting smoking. I hope Professor Chapman will reflect carefully on what harms might be caused if his ideas are taken seriously by policy-makers.

I also made what I think is a reasonable point about the incentives of the companies involved: that e-cigarette sector has a very large market of adult smokers to pursue as their potential customer base (this also applies to the tobacco owned e-cigarette companies who are fighting over market share). Adult smokers is where the data shows that they overwhelmingly do find their customers. The e-cigarette sector is small in every country compared to the cigarette trade (about $6 billion globally compared to $800 billion for the tobacco trade) so there is plenty of room to grow by eating into the cigarette trade. These companies would create unnecessary risks for themselves if they targeted teenagers, and they have no need to.

Even if not targeted, some teenagers will use these products. Most public health experts are familiar with the idea that some adolescents engage in risky behaviours and try adult things, and I hope that isn’t a revelation to anyone in the field of tobacco control. The data show that the teenagers who do use these products are almost all smokers already or have ‘risk factors’ that mean they are likely to become smokers. To the extent it is displacing smoking, e-cigarette use may be creating a health dividend. It’s too soon to say if that is actually happening, but the trends are largely consistent with that effect and Professor Chapman should expand his thinking to accommodate that possibility.

As far as consistency is concerned, in 2000 while still Director of ASH I was open-minded about the concept of the tobacco market evolving to low-risk nicotine products and even envisaged the challenge that this would create for some factions in the public health establishment. See my paper ‘What is the future for the tobacco industry” from Tobacco Control journal in 2000 and especially the section “How can the tobacco market evolve”, in which I imagine the rise of products a bit like e-cigarettes…

http://tobaccocontrol.bmj.com/content/9/2/237.full

What I said in 2000 about the future of the nicotine and tobacco market is, I think, a fairer test of consistency of my approach to e-cigarettes than what I said at the time about something completely different.

My article from 2000 is not perfectly correct about the rise of e-cigarettes, but as a bit of crystal-ball gazing it is not a bad account of what has come to pass. Neither is it inconsistent with what I’m saying now. I was warning even then that we would need to put health first if the market evolved in this way, which it duly has done: leaving the much of the tobacco control community confused about its mission.

Regrettably, this blog contains unfounded innuendo about my purpose that readers should discount. I don’t wish to engage Professor Chapman in personal animus, but I would like to explain my own motivation. I believe the ‘harm reduction’ agenda is a legitimate public health strategy in drugs, sexual health, alcohol and other fields within public health – and there is every reason to apply it to smoking. I have been consistent about this since 1998. I put a lot of time into this issue because I believe it has the potential to avoid hundreds of millions of premature smoking-related deaths in the 21st Century by making the cigarette obsolete for many or most users. Furthermore, I think it is consistent and synergistic with legitimate evidence-based tobacco control policy – the more you press people to stop smoking with punitive or coercive measures, the more important it is to have somewhere for committed or addicted smokers to go. That’s an ethical argument that tobacco control advocates would do well to embrace if they wish to succeed in their mission.

NutmegJunkie

Nicotine, when administered via a tobacco free technology like an electronic vaporiser, is a not a threat to public health. In case you didn’t know, caffeine has also been identified as a causative agent in psychosis[1]. Does that mean we should reclassify caffeine as a threat to public health like you are suggesting nicotine we do with nicotine?

1. http://scholar.google.com.au/scholar?hl=en&q=caffeine+psychosis&btnG=&as_sdt=1%2C5&as_sdtp=

Mister Blog Dog

QUOTE: “In the USA today data from the US National Youth Tobacco Survey show that while cigarette smoking continues to fall in US teenagers, e-cigarette use has been dramatically increasing since 2011 and is now way ahead of cigarette smoking” – Prof Simon Chapman

The survey you cite is badly flawed because it classed a teenage user as someone who had taken as little as a single puff on an e-cigarette in the previous 30 days, with no attempt to establish regular usage or even if the e-cigarette contained nicotine.

The latest CDC survey (published in Nov. 2015) involving 36,000 participants, found that e-cigarette use was largely confined to smokers and former smokers. In fact, the survey found that only 0.04% of never smokers went on to become regular e-cigarette users.

Prof Chapman. If you are going to cite a survey to reinforce your criticisms of people who you disagree with, please first make some attempt verify the quality of the survey.

Many thanks.

Simon_Chapman

Clive Bates reiterates his central argument that the tobacco industry and the ecigarette industry and their products are “completely different”, and that therefore what he wrote in Danger PR in the Playground (http://www.ash.org.uk/files/documents/ASH_625.pdf) in 2000 about the tobacco industry is irrelevant to the ecigarette industry.

So how completely different are these industries? Both sell products with the word “cigarette” front and centre. Both sell nicotine delivery systems engineered to rapidly maximise repeat purchasing. Both cigarettes and ecigarettes involve repeated hand-to-mouth activity and the semiotically rich smoking performance of exhaling smoke/vapour. Marketers in both industries understand completely that their future commercial health is dependent on maximising addiction, attracting already nicotine dependent people to their brands, and, critically for the future, attracting those who have never used nicotine before (mostly kids).

Bates fails to engage with my argument about the tobacco industry’s public virtues/private vices duplicity and why the very same public relations strategy would not also suit the ecigarette industry’s commercial goals. Does he really imagine that in the USA where today there are 340,000 children vaping more than 20 days a month, that ecigarette industry investors are anything less than ecstatic?

My blog post was about what I consider the folly of allowing the sort of open slather advertising for ecigarettes we see now in some nations. The 53 signatories of the letter to Margaret Chan agreed that “Controls on [ecigarette] advertising to nonsmokers, and particularly to young people are certainly justified” and that “It is possible to target advertising at existing smokers where the benefits are potentially huge and the risks minimal.”

So when a vaping adult on the couch next to their 10 year old sees a TV ad for a gummy bear flavoured product, how does it target the adult, but go right over the child’s head? Please enlighten us Clive.

He argues that “the odd rogue advertisement” for ecigarettes may get through industry advertising self-regulation systems, but that in England this system is working well. I suggest that Clive should read his own work far more carefully. On page 22 of Danger PR in the Playground he will find a section explaining why voluntary advertising codes have “failed” and that “voluntary agreements have served the industry well and the public badly”.

Blithe dismissals of teenage vaping as some kids just “trying adult things” ignore the unprecedented success that several nations have had in the last decade in dissuading hundreds of thousands of kids from ever just trying cigarettes (or any form of nicotine).

Bates says that ecigarettes help “people to quit smoking.” There are certainly many people who attribute their smoking cessation to ecigarettes, but the best population cohort study we have (from England) shows (http://onlinelibrary.wiley.com/doi/10.1111/add.12917/epdf) that at 12 months “Daily use of e-cigarettes while smoking appears to be associated with subsequent increases in rates of attempting to stop smoking and reducing smoking, but NOT with smoking cessation.” (my emphasis). To the great delight of the tobacco companies, the most common scenario for even daily vapers is dual use. The Brose et al paper from England (http://onlinelibrary.wiley.com/doi/10.1111/add.12917/epdf) reported that at 12 months, 13.9% of daily e-cigarette users reduced cigarette smoking substantially. But let’s turn the last figure around. Even among those smokers who vaped daily, 86.1% did not even cut back smoking substantially. That’s how good e-cigarettes are at just reducing smoking.

I have never made any public statement supporting the prohibition of either cigarettes or ecigarettes. Clive and I have common ground in sharing the belief that committed or addicted smokers should be able to access products that satisfy their craving and that ecigs are almost certainly going to be far less hazardous than smoked tobacco.

But it does not follow from this that such access should be a free-for-all, with unrestricted advertising and unregulated products. Charlotta Pisinger’s updated review of the evidence presented at the recent ecigarette summit (not yet online) should give much pause to those thinking that ecigs are as “harmless as coffee” and should be regulated to an equivalent degree.

There are only two nations in the world – the USA and New Zealand – where direct-to-consumer advertising of prescription drugs is allowed. These drugs are designed to save lives, restore health, ease severe pain etc. Almost every household at any time has people using prescribed drugs. Sometimes these are for life, sometimes for limited periods. These limitations on accessing and publicising these products do not see mass consumer wailing about
heinous restrictions. There are not queues of governments lining up to adopt the US approach to prescribed drug advertising.

We made every mistake possible in how cigarettes were sold and marketed. We need not repeat the same mistakes with ecigarettes.